SPECTRUM dialogue Techno-Clinical Day OCTOBER 12, 2012 Hilton Suites Conference Centre & Spa (Toronto/Markham) 8500 Warden Ave, Markham, ON L6G 1A5 (Please complete sections A – C) Fax Completed form to: 905.489.1971
Mail form to: SPECTRUM dialogue Techno-Clinical Day TORONTO
34 - 145 Royal Crest Court, Markham, ON, L3R 9Z4
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Register Online: www.spectrum-day.com Questions? Call: 905.489.1970
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1.866.581.8949 • Email: events@palmeripublishing.com
A. Contact Information: (please print) 1) First Name:___________________________________ Last Name:_______________________________ RDT
DDS
DD
2) First Name:___________________________________ Last Name:_______________________________ RDT
DDS
DD
3) First Name:___________________________________ Last Name:_______________________________ RDT
DDS
DD
Company: ___________________________________________________________________________________________________ Address: ____________________________________________________________________________________________________ City: ___________________________________________________ Pro/State: ______________ Postal/Zip Code: _______________ Phone: _________________________________________________ Fax: _______________________________________________ Email: __________________________________________________________________________________________________________
B. I am a: Dentist
Dental Assistant
Hygienist
Dental Technologist
Technician
Denturist
Orthodontist
Other: Please specify: ___________________________________________________________________________________________
C. I am a Member of: (check all that apply) ADTO
CACD
CAED
ODA
ADIA
DTA
SADA
OAGD
Other: Please specify: ___________________________________________________________________________________________
if you N O I S S I M FREE AD in advance! r registe .00 at the door) ($59
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SPECTRUM dialogue Techno-Clinical Day TORONTO
9/13/2012 9:23:54 AM